BioMed Central Page 1 of 14 (page number not for citation purposes) BMC Psychiatry Open Access Research article Returning home: forced conscription, reintegration, and mental health status of former abductees of the Lord's Resistance Army in northern Uganda Phuong N Pham* †1,2 , Patrick Vinck †1,2 and Eric Stover 3 Address: 1 Human Rights Center, University of California, Berkeley, Berkeley, CA, USA, 2 Payson Center for International Development, Tulane University, New Orleans, LA, USA and 3 Human Rights Center, School of Public Health, and School of Law, University of California, Berkeley, Berkeley, CA, USA Email: Phuong N Pham* - ppham1@berkeley.edu; Patrick Vinck - pvinck@berkeley.edu; Eric Stover - stovere@berkeley.edu * Corresponding author †Equal contributors Abstract Background: Since the late 1980s, the Lord's Resistance Army (LRA), a spiritualist rebel group in northern Uganda, has killed and mutilated thousands of civilians and abducted an estimated 52,000 to 75,000 people to serve as soldiers, porters, and sex slaves for its commanders. This study examines the types of violence to which former abductees have been exposed and the extent to which these acts have affected their psychological well-being. Methods: This is a cross-sectional study of 2,875 individuals selected through a multi-stage stratified cluster sampling design conducted in 8 districts of northern Uganda. Multivariate logistic regressions were performed with symptoms for Post-traumatic Stress Disorder (PTSD) and depression as the main outcome measures. Results: One-third of the respondents (33%) self-reported having experienced abduction (49% among the Acholi, the largest tribal group in northern Uganda). Over half (56%) of all the respondents and over two- thirds of those who experienced abduction met the criteria for symptoms of post-traumatic stress disorder (PTSD). Multivariate analysis shows that several factors increased the risk of former LRA abductees developing symptoms of PTSD. These factors included gender (females were more susceptible than males), being a member of the Acholi ethnic group, participating in or witnessing a cumulative number of traumatic events, and encountering difficulties re-integrating into communities after abduction. Factors associated with increased risk of meeting criteria for symptoms of depression included older age of males at the time of abduction, lower score on social relationship scale, high incidence of general traumatic event exposure, high incidence of forced acts of violence, and problems reintegrating into communities after abduction. Conclusion: Abduction and forced conscription of civilians has affected the psychological well-being of a significant number of northern Ugandans. The sources of psychological trauma are multiple, ranging from witnessing to being forced to commit violent acts, and compounded by prolonged exposure to violence, often for months or years. Community-based mental health care services and reintegration programs are needed to facilitate the reintegration of former abductees back into their communities. Published: 16 May 2009 BMC Psychiatry 2009, 9:23 doi:10.1186/1471-244X-9-23 Received: 26 November 2008 Accepted: 16 May 2009 This article is available from: http://www.biomedcentral.com/1471-244X/9/23 © 2009 Pham et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 2 of 14 (page number not for citation purposes) Background Twenty-one years of war, destruction, and the displace- ment of over 1.5 million people have turned northern Uganda into a humanitarian disaster. One of the principal belligerents in the conflict has been the Lord's Resistance Army (LRA), a spiritualist rebel group that has killed and mutilated thousands of civilians and abducted an esti- mated 52,000 to 75,000 children and adults to serve as soldiers, porters, and sex slaves for its commanders [1]. In response, the International Criminal Court (ICC) issued warrants of arrest, on 13 October, 2005, against LRA leader Joseph Kony and four of his top commanders for crimes against humanity and war crimes, including the forced conscription of children [2]. Within weeks, the LRA withdrew its forces to the southern Sudan and then crossed the Nile, assembling in Garamba National Park in the Democratic Republic of Congo. In the summer of 2006, peace talks between the Government of Uganda and the LRA commenced in Juba, Sudan but collapsed eighteen months later when Kony refused to sign a final peace agreement. By February 2009, hundreds of thou- sands of Ugandans remained in displacement camps throughout the North and, in eastern Congo, the LRA rebels and joint Ugandan-Congolese troops were engaged in armed skirmishes. While abduction of children and youth into regular and rebel armies has been a common feature of recent armed conflicts (Sri Lanka, Nepal, Angola, Mozambique, Sierra Leone, Liberia, Uganda, Burma), little is known about the process of reintegrating former abductees back into their communities [3]. Until early 2007, community and inter- national humanitarian organizations in northern Uganda had operated 12 reception centers for LRA abductees who were either captured in battle or managed to flee their cap- tors [1,4-6]. Upon arrival, former abductees were given a medical exam and treated for diseases and other ailments. Those suffering from war wounds were sent to hospitals in Gulu and Kampala. Most returnees stayed at the centers for two to six weeks were the participated in a range of activities, including counseling, music and dance, sports, and vocational training. During that time, staff members attempt to trace the whereabouts of their parents and rel- atives and, if successful, the former abductees would be reunited with their parents or other relatives. To understand how abduction and the process of reinte- gration had affected former LRA combatants we analyzed a cross-sectional survey that was conducted in eight dis- tricts of northern Uganda between March and June 2007. Methods Survey Sites and Sample Selection Study participants were Ugandan adults (18 years of age or older) randomly selected using a multi-stage sampling strategy. The Committee for Protection of Human Sub- jects at Tulane University and University of California, Berkeley, and northern Uganda local government officials approved the research protocol. No incentive was pro- vided to the survey participants. The districts were selected to represent a variety of ethnic groups (Acholi, Iteso, and Langi) and exposure to the armed conflict (Figure 1). The resulting minimum sample size–320 individuals for each district–was determined using the difference in propor- tion formula. The sample size was adjusted for stratifica- tion and design effect due to cluster sampling and missing responses. The assumed level of precision was 10% with 80% power. Within each district, camps for internally dis- placed people were randomly selected using a sampling technique proportionate to population size. In some cases, residents of the camps had recently moved to new settlement sites closer to their original villages. In order to capture this population, we randomly selected one new settlement site for each of the selected camps where pop- ulation movement had taken place, based on the database provided by the World Food Programme (WFP) and the United Nations High Commission for Refugees (UNHCR). In areas where the population was never dis- placed or had returned to live in villages, sub-counties were first sampled using a sampling technique propor- tionate to population size, then parishes and then vil- lages. In the camps and villages, interviewers were assigned to zones of approximately equal size where they selected every other household in a randomly chosen direction. A household was defined as a group of people normally sleeping under the same roof and eating together. In each household, interviewers randomly selected one adult respondent, of the same gender as the interviewer, from a list of all eligible adults. Three attempts were made to contact a household or individual. Three teams of eight to 16 local university students or graduates with experience in survey work participated in a week-long training to familiarize themselves with the standardized pre-coded open-ended questionnaire, inter- view techniques, and selection process for respondents. The teams were composed of equal numbers of men and women, represented the ethnic group of the area under study and were fluent in the local language. The training included a pilot survey in non-sampled sites. Data were collected using Personal Digital Assistants (PDA) with integrated Global Positioning System (GPS). The inter- viewers attended an additional three day of training on the use of the PDA. Interviewers approached a total of 4,455 households and 2,875 individuals were ultimately interviewed. One third (35%) of the households was replaced by the next selected household either because the household was empty and no one could be contacted after three attempts (64%), BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 3 of 14 (page number not for citation purposes) because no one was eligible in the household (no one 18 years of age or older (24%), or because they refused to participate (12%). Within the selected households, one individual was randomly selected. If that person could not participate, another respondent within the same house- hold was selected. In total, 20 of the selected individuals had to be replaced either because they were absent or could not be contacted after three attempts (78%) or because they refused to participate (22%). Two interviews were conducted mistakenly with individuals aged below 18 years old and were not included in the analysis. Eleven interviews were not completed but the completed responses are nevertheless included in the analysis. The final sample size for the eight districts was 2,875 individ- uals in 38 camps, 21 new sites, 59 villages, and nine municipalities or town councils. The sample was distrib- uted as follow (by district): Amuru: 347; Gulu: 335; Kit- gum: 370; Pader: 352; Lira: 365; Oyam: 357; Amuria: 394; Soroti: 355. Research Instruments and Data Entry The survey instrument covered 15 topics and was trans- lated into the three local languages. Back-translation and consultation with local experts was used to ensure the quality of the translation. The questionnaire was field tested and validated in non-participating sites and mock interviews were organized during the training of the inter- viewers. Response options were provided to the interviewer but not read to the participant unless otherwise indicated. An "other" category was available to record responses when necessary or when the interviewers were unsure of the appropriate response option; it was recoded during anal- ysis. Each evening the data were synchronized with a cen- tral MySQL database and records were manually checked for errors. One-on-one interviews were conducted anony- mously in a confidential setting. Due to the sensitivity of some of the questions, the interviewers were assigned to Eight sampled districts in northern UgandaFigure 1 Eight sampled districts in northern Uganda. ! ! ! ! ! ! Gulu Kitgum Pader Oyam Lira Amuria Soroti Kampala Adjumani Masindi Moyo Apac Dokolo Kaberamaido Amolatar Kumi Katakwi LIRA DISTRICT (LANGO) Sample size: n = 365 in 7 camps, 15 villages, 1 municipality Lira Gulu Hoima Soroti Kitgum Masindi Amuru Moroto Kaabong Kotido Abim Tanza nia D.R. Congo Sudan Kenya Uganda . 0255012.5 Kilometers Map by Vinck P Data Source: Administrative limits provided by CartONG AMURU DISTRICT (ACHOLI) Sample Size: n = 347 in 6 camps, 3 new sites GULU DISTRICT (ACHOLI) Sample Size: n = 335 in 4 camps, 4 new sites, 1 municipality KITGUM DISTRICT (ACHOLI) Sample Size: n = 370 in 5 camps, 6 new sites, 1 municipality A c h o l i S u b r e g i o n L a n g o S u b r e g i o n T e s o S u b r e g i o n PADER DISTRICT (ACHOLI) Sample size: n = 352 in 5 camps, 4 new sites, 1 municipality OYAM DISTRICT (LANGO) Sample Size: n = 357 in 4 camps, 10 villages, 3 Town Council SOROTI DISTRICT (TESO) Sample Size: n = 355 in 2 camps, 29 villages, 1 municipality AMURIA DISTRICT (TESO) Sample size: n = 394 in 5 camps, 5 villages, 4 new sites, 1 municipality BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 4 of 14 (page number not for citation purposes) same-sex respondents. Oral rather than written consent was obtained due to the high illiteracy rate. The consent form stressed confidentiality and respondents' names were never recorded. Measurements and Data Analysis Digital data from the interviews were imported and ana- lyzed using Statistical Package for Social Science (SPSS) version 15.0. No weights were applied for the present study. Scores for the 17-item PTSD Checklist-Civilian Ver- sion (PCL-C), a measure of post-traumatic stress disorder, and 15-item depression section of the Johns Hopkins Depression Symptom Checklist (JHD) were computed to assess symptoms of PTSD (cutoff score of 44) and depres- sion (cutoff score of 42), respectively. The PCL-C, which has been correlated with the Clinician-Administered PTSD Scale (CAPS), uses simple language that eases the process of translation and administration by nonclini- cians to a population with low levels of education, and has been shown to have good internal reliability and high convergent validity in a wide variety of studies [7]. In addition, the PCL-C and JHD had good reliability when used by the investigators for this and prior study in Uganda [8] and other countries including Rwanda and Democratic Republic of Congo [9-11]. The estimated Cronbach α (a measure of internal reliability) for the three PCL-C symptom clusters in this study were as fol- lows: re-experiencing, α = .875; avoidance, α = .860; and hyperarousal, α = .850. The estimated Cronbach α for the Depression Symptom checklist was α = .927. Building on previous research in northern Uganda [8], we developed a list of 33 items to measure exposure to vio- lence and experience of abduction. The list does not rep- resent all possible traumatic events but rather focuses on commonly reported events. Building on measurements of exposure to violence [12], four summative scales were built to measure exposure to different categories of violent events: direct victim of violence (e.g., being beaten); wit- ness to violence; secondary exposure (e.g., loss of a family member); and forced use of violence (e.g., being forced to loot or beat someone). We developed a measure of social relationship based on three questions asking respondents to rank their relation- ship with their family, friends and neighbors, and com- munity in general on a five-point Likert scale. Principal component analysis was used to analyze the three items and resulted in one factor explaining 74.1% of the origi- nal variance. A summative scale based on the original items was therefore used as a measure of social relation- ship (Cronbach α = .820). We performed two separate multivariate logistic regres- sions to examine factors associated with psychological disorders (symptoms of PTSD and depression) among respondents who reported experiencing abduction. The predictors of greatest interest were exposure to violence (summative scale by patterns of exposure), length of abduction, going through a reception center, and social relationship. Logistic regressions analysis allows one to compute an odds ratio, an estimate of relative risk, and is easier to interpret in exploring the complex relationships presented in this paper. We performed both forward- and backward-stepwise hierarchal regressions. Only the statis- tically significant predictors were included in the final models. Results General Characteristics of Abductees Of 2,867 respondents with complete information on experience of abduction, 946 (33%) reported they had been abducted at one time or another during the course of the 20-year conflict in northern Uganda. Among them, 46% stated that they had been abducted on two or more occasions. In the Acholi sub-region, almost half of the respondents (49%) stated that they had been abducted compared to one-fifth (22%) in the Lango subregion and one-tenth (11%) in the Teso subregion. This pattern is reflected in the proportion of former abductees by ethnic group since ethnic distribution roughly follows adminis- trative limits. As shown in Table 1 women accounted for 410 (43%) of the 946 respondents who reported experiencing abduc- tion. Males were more likely to have reported abduction (OR undj = 1.44, 95% C.I. = 1.23, 1.68) compared to females. The mean age of respondents who reported abduction was 35.3 at the time of the survey (S.D. 13.51) similar to the mean age of those who did not report abduction (35.2). At the time of their first abduction, respondents who were held in captivity averaged 25.8 years old (S.D. 13.57). A majority of those who were held in captivity were in a committed relationship, either mar- ried (71.8%) or in a partnership (3.6%). About a quarter (24.8%) of the abducted had no education and 40% had some but incomplete primary education. Formerly abducted respondents further self-identified as Catholic (70.2%) more frequently than non-abducted respondents (57.8%). Of those who reported abduction, 426 (45%) were held for less than a day, 199 (21%) were held captive for one to seven days, and 122 (13%) were held for between one week and one month. One hundred and two respondents (11%) were held for about one to six months and 97 (10%) for more than six months. Exposure to Traumatic Events and War Crimes Exposures to four categories of violent traumatic events were assessed: direct victim (e.g., being beaten), witness to violence, secondary exposure (e.g., loss of a family mem- BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 5 of 14 (page number not for citation purposes) Table 1: Socio-Demographic Profile of Respondents by Abduction Status All Not Abducted Abducted n 2,867 1,921 946 (100%) (67%) (33%) Gender (women) 1,417 1,007 410 (49.5%) (52.4%) (43.4%) Mean Age 35.4 35.42 35.26 (S.D.) (14.35) (14.75 (13.51) Mean Age at Abduction - - 25.84 (S.D.) - - (13.57) Mean Income, Ugandan Shillings (S.D.) 33,426 35,804 28,701 (166,885) (199,492 (60,874) Ethnicity Acholi 1,385 706 679 (48.3%) (36.7%) (71.8%) Langi 712 633 79 (24.8%) (32.9%) (8.4%) Teso 724 540 184 (25.2%) (28.1%) (19.5%) Other 47 43 4 (1.6%) (2.2%) (0.4%) Marital Status Single 373 265 108 (13.0%) (13.8%) (11.4%) Married 2,070 1,391 679 (72.2%) (72.4%) (71.8%) Partner 77 43 34 (2.7%) (2.2%) (3.6%) Divorced 130 78 52 (4.5%) (4.1%) (5.5%) Widowed 217 144 73 (7.6%) (7.5%) (7.7%) Religion Catholic 1,771 1,108 663 (61.9%) (57.8%) (70.2%) Protestant 802 580 222 (28.0%) (30.2%) (23.5%) Born Again 227 177 50 (7.9%) (9.2%) (5.3%) Other 63 53 10 (2.2%) (2.8%) (1.1%) BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 6 of 14 (page number not for citation purposes) ber), and forced to use violence (e.g., being forced to loot or beat someone). While exposure to violence was wide- spread among respondents, former LRA abductees reported higher level of exposure in all four categories (see Table 2). The average cumulative number of reported events within each category was also higher among former LRA abductees (p-value < .001). Returning home Among those who were abducted less than one day, 67% reported they were released by the LRA compared to 32% of those held captive one to seven days and 18 among those held captive between eight days and one month (see Table 3). Conversely, 78% of those who were held for six months or more escaped compared to 57% among those captive one to seven days and 26% among those abducted less than one day. Thirteen percent of the respondents said they had spent time in a reception center (see Table 3). One half (49%) of those abducted for six months or more reported to a reception center, compared to 2% of those abducted for a day or less. Overall, men were 1.76 times more likely to report that they had gone through a reception center than women (OR = 1.77, 95% C.I. = 1.18, 2.63, p-value = .005). However, the proportion of women going through reception centers was higher than that of men, at 52% compared to 47% ( χ 2 = 7.96, df = 1, p-value = 0.005). Among those who went through a reception center, four out of five (88%) reported that the reception center helped them return to their communities, and almost half reported that they received follow-up visits from reception center staff. Thirty-nine percent of former LRA abductees reported problems upon returning to their home communities. In addition, former LRA abductees who spent six or more months with the rebels (68%) reported more problems after returning home than those who stayed less time. While physical and material concerns were frequently mentioned ("health" and "injury": 18.9%; "loss of prop- erty" and "goods": 10.6%), most of those who returned reported mental and social problems ("mentally do not feel well": 10.6%; "problems adjusting to life outside the bush": 16.7%; "relationship problems with family": 10.8%). Symptoms of PTSD and Depression Among Former Abductees Among respondents with a complete response to all items on the PCL-C and the Johns Hopkins Symptom Checklist who reported being abducted, 67% met the criteria for symptoms of PTSD and 40% met the criteria for symptom depression, compared to 51% and 25.9% respectively among those who were not abducted (see Table 4). Com- pared to non-abductees, those abducted were twice as likely to meet the criteria for symptoms of PTSD (OR undj = 2.12, 95% C.I. = 1.81, 2.51) and symptoms of depression (OR undj = 2.07, 95% C.I. = 1.75, 2.45). Respondents abducted for six months or more frequently met the crite- ria for symptoms of PTSD (80%) and symptoms of depression (47%) than those abducted for shorter peri- ods. After statistically controlling for the effect of other varia- bles by employing multivariate logistic regression, report- ing symptoms of PTSD was associated with gender, ethnicity, problems returning home, cumulative exposure as a witness, and cumulative exposure to forced acts of violence (see Table 5). Females were almost nine times more likely to report symptoms of PTSD (OR adj = 8.84, 95% C.I. = 6.07, 12.88). Among abductees, Acholi were three times more likely to meet symptom criteria for PTSD than Iteso (OR adj = 3.05, 95% C.I. = 1.59, 5.87). Langi were twice as likely to meet symptom criteria for PTSD than Iteso (OR adj = 2.15, 95% C.I. = 1.05, 4.41). There was no significant difference between Acholi and Langi respondents. Cumulative number of traumatic events wit- nessed (OR adj = 1.21, 95% C.I. = 1.10, 1.32) and cumula- tive number of forced acts of violence (OR adj = 1.43, 95% C.I. = 1.18, 1.74) among abductees were associated with meeting criteria for symptoms of PTSD. Finally, former abductees who reported difficulties coming home to their community after abduction were nearly three times more Education No schooling 698 473 225 (24.3%) (24.6%) (23.8%) Some primary 1,073 691 382 (37.4%) (36.0%) (40.4%) Completed primary 459 314 145 (16.0%) (16.3%) (15.3%) Higher than primary 638 444 194 (22.2%) (23.1%) (20.5%) Table 1: Socio-Demographic Profile of Respondents by Abduction Status (Continued) BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 7 of 14 (page number not for citation purposes) Table 2: Exposure to Traumatic Events and War Crimes All Not Abducted Abducted Direct Violent Exposure Was displaced 2,450 1,546 904 (85.4%) (80.4%) (95.6%) Lost income due to conflict 2,441 1,562 879 (85.1%) (81.3%) (92.9%) House destroyed 2,412 1,505 907 (84.1%) (78.3%) (95.9%) Lost productive assets 2,387 1,490 897 (83.2%) (77.5%) (94.8%) Was beaten by the LRA 587 57 540 (20.8%) (3.0%) (57.1%) Was maimed by the LRA 173 23 150 (6.0%) (1.2%) (15.9%) Was sexually violated 61 22 39 (2.1%) (1.1%) (4.1%) Problem with UPDF 645 369 276 (22.5%) (19.2%) (29.2%) Forced by LRA to walk long distances 833 89 744 (29.0%) (4.6%) (78.6%) Forced by LRA to carry loads 727 26 701 (25.30%) (1.4%) (74.1%) Mean Cumulative General Exposure (S.D.)* 4.94 4.16 6.61 (2.00) (1.79) (1.28) Exposure as Witness Witnessed an attack by LRA 1,988 1,114 874 (69.3%) (58.0%) (92.4%) Witnessed LRA/UPDF fight 1,259 653 606 (43.9%) (34.0%) (64.1%) Witnessed an abduction 1,812 935 877 (63.2%) (48.6%) (92.7%) Witnessed s.o. beaten by LRA 1,531 718 813 (53.4%) (37.4%) (85.9%) Witnessed s.o. beaten by UPDF 1,187 662 525 (41.4%) (34.4%) (55.5%) Witnessed s.o. killed by the LRA 931 406 525 (32.5%) (21.1%) (55.5%) Witnessed HH member killed by LRA 709 307 402 (24.7%) (16.0%) (42.5%) BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 8 of 14 (page number not for citation purposes) Witnessed s.o. sexually violated by LRA 249 84 165 (8.7%) (4.4%) (17.4%) Witnessed s.o. sexually violated by other 243 111 132 (8.5%) (5.8%) (14.0%) Mean Cumulative Witness Exposure (S.D.)* 32.475.19 (2.57) (2.43) (1.86) Secondary Exposure At least 1 family member killed 2,115 1,272 843 (73.7%) (66.2%) (89.1%) Spouse/Partner killed 88 53 35 (3.1%) (2.8%) (3.7%) Mother killed 141 73 68 (4.9%) (3.8%) (7.2%) Father killed 304 159 145 (10.6%) (8.3%) (15.3%) Brother killed 870 466 404 (30.3%) (24.2%) (42.7%) Sister killed 257 132 125 (9.0%) (6.9%) (13.2%) Son killed 226 132 94 (7.9%) (6.9%) (9.9%) Daughter killed 72 41 31 (2.5%) (2.1%) (3.3%) Grandmother killed 74 48 26 (2.6%) (2.5%) (2.7%) Grandfather killed 117 83 34 (4.1%) (4.3%) (3.6%) Family member was abducted 1,106 582 524 (38.6%) (30.3%) (55.6%) Mean Cumulative Secondary Exposure (S.D.) 1.15 0.93 1.61 (1.10) (1.04) (1.10) Forced Acts of Violence During Captivity by the LRA Forced to loot NA NA 353 (37.2%) Forced to beat or injure someone NA NA 167 (17.6%) Forced to kill someone NA NA 76 (7.6%) Mean Cumulative Forced Acts of Violence (S.D.) NA NA 0.62 (0.92) *p-value < .001 for difference in mean cumulative exposure between abducted and non-abducted people Table 2: Exposure to Traumatic Events and War Crimes (Continued) BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 9 of 14 (page number not for citation purposes) Table 3: Experiences Returning Home among Former Lord's Resistance Army Abductees Abducted < 1 day 1–7 days 8 days – < 1 month 1 – < 6 months > 6 months Means of Return Released by LRA 282 63 22 11 6 (67.0%) (32.0%) (18.3%) (11.2%) (6.3%) Escaped 111 112 80 79 74 (26.4%) (56.9%) (66.7%) (80.6%) (77.9%) Rescued by UPDF 26 22 17 8 14 (6.2%) (11.2%) (14.2%) (8.2%) (14.7%) Other 2 0 1 0 1 (0.5%) (0.0%) (0.8%) (0.0%) (1.1%) Went through Reception center 822 21 28 47 (1.9%) (11.0%) (17.2%) (27.7%) (48.5%) Helped return in community 2 20 20 23 46 (25.0%) (90.9%) (95.2%) (82.1%) (97.9%) Was visited by center's staff after return 1 10 14 13 23 (12.5%) (45.5%) (66.7%) (46.4%) (48.9%) Had Problem Returning Home 104 74 67 60 66 (24.4%) (37.0%) (54.9%) (59.4%) (68.0%) Type of Problems Stigmatization 4 34 7 10 12 (4.0%) (4.20%) (11.30%) (16.7%) (18.2%) "Mentally do not feel well" 10 8 8 5 7 (9.9%) (11.3%) (12.9%) (8.3%) (10.6%) Problem with adjusting to life outside the bush 8 3 9 10 11 (7.9%) (4.2%) (14.5%) (16.7%) (16.7%) Difficulty with school, work 9 7 4 7 13 (8.9%) (9.9%) (6.5%) (11.7%) (19.7%) Relation problems, family 9 9 9 6 6 (8.9%) (12.7%) (14.5%) (10.0%) (9.1%) Relations problems, friends/neighbors 6 3 8 4 3 (5.9%) (4.2%) (12.9%) (6.7%) (4.5%) Health, injury 18 26 8 9 7 (17.8%) (36.6%) (12.9%) (15.0%) (10.6%) Loss of property/goods 17 8 6 5 2 (16.8%) (11.3%) (9.7%) (8.3%) (3.0%) Other 20 4 3 4 5 (19.8%) (5.6%) (4.8%) (6.7%) (7.6%) BMC Psychiatry 2009, 9:23 http://www.biomedcentral.com/1471-244X/9/23 Page 10 of 14 (page number not for citation purposes) likely to meet criteria for symptoms of PTSD at the time of the survey (OR adj = 2.97, 95% C.I. = 2.09, 4.24). Multivariate logistic regression analysis showed that meet- ing symptoms of depression was associated with gender, relationship with family, difficulties returning home, cumulative direct violent traumatic exposure, and cumu- lative exposure to forced acts of violence (see Table 5). Interactions between age and gender were also significant. Among abductees, women were twice as likely as men to report symptoms of depression (OR adj = 2.11, 95% C.I. = 1.22, 3.63). Due to statistical interaction between age and gender, each one-year increase in age is associated with multiplicative increase in odds of having symptoms of depression by 3% among men and decrease in odds of having symptoms of depression by 2% among women. This means that while male abductees may have an increased risk of having symptoms of depression as they age, the risk for female abductees may decrease with age. Higher self-reported positive scores for abductees' rela- tionships with their family, friends, and community were associated with a decrease in odds of meeting the criteria for symptoms of depression (OR adj = 0.90, 95% C.I. = 0.83, 0.97). Likewise, reported problems when returning were positively associated with the odds of meeting the criteria for symptoms of depression (OR adj = 2.24, 95% C.I. = 1.63, 3.08). The cumulative number of general trau- matic exposures (OR adj = 1.18, 95% C.I. = 1.03, 1.33) and cumulative number of forced acts of violence (OR adj = 2.24, 95% C.I. = 1.63, 3.08) were associated with increased odds of meeting the criteria for symptoms of depression among abductees. The following variables were not statistically associated with either symptoms of PTSD or depression in the multivariate analyses described Table 4: Psychosocial Well-being Among Former Lord's Resistance Army Abductees Not Abducted Abducted Abducted < 1 day 1–7 days 8 days – < 1 month 1 – < 6 months >6 months Symptoms of Depression Total 481 373 160 77 55 36 45 (25.9%) (40.4%) (38.6%) (39.5%) (47.0%) (35.3%) (47.4%) Men 125 146 38 34 29 17 28 (14.0%) (27.8%) (20.0%) (28.8%) (35.8%) (24.6%) (41.2%) Women 355 227 122 43 26 19 17 (36.8%) (57.3%) (54.7%) (55.8%) (72.2%) (57.6%) (63.0%) Total Symptoms for PTSD Total 938 613 259 126 83 70 75 (50.6%) (67.1%) (62.7%) (65.3%) (72.8%) (70.7%) (79.8%) Men 306 274 73 57 51 42 51 (34.6%) (52.6%) (38.8%) (48.7%) (63.8%) (61.8%) (75.0%) Women 630 338 185 69 32 28 24 (65.2%) (86.4%) (82.6%) (90.8%) (94.1%) (90.3%) (92.3%) Cluster: Reexperiencing 1,351 763 334 161 108 79 81 (71.3%) (81.5%) (79.0%) (82.6%) (90.0%) (78.2%) (83.5%) Cluster: Avoidance/numbing 861 563 233 118 77 62 73 (45.5%) (60.4%) (55.3%) (59.6%) (65.3%) (61.4%) (77.7%) Cluster: Hyperarousal 1,079 676 299 141 87 75 74 (56.8%) (72.5%) (71.0%) (71.6%) (73.7%) (74.3%) (77.1%) Relationship with family and community, Mean (S.D.) 12.01 12.26 12.4 12.26 12.04 12.03 12.08 (2.01) (1.88) (1.78) (1.74) (1.94) (2.09) (2.19) [...]... services and reintegration programs in northern Uganda This study corroborates other studies that found family and community play an important role for the psycho-social well being of former abductees [15] Thus addressing psychological trauma and helping former abductees reunite with their family and community are paramount to facilitating the return to their communities of those held in captivity The research... supported by grants from the John D and Catherine T MacArthur Foundation and Humanity United The sponsors of the study had no role in the design of the study, data collection, data analysis, data interpretation or writing of the report We wish to thank our field surveyors and the survey respondents for taking the time to share their views with us We also would like to thank Drs Harvey Weinstein and Janet... Blattman C: Survey of War Affected Youth Kampala, United Nation Children's Fund; 2006 Amone-P'Olak K: Coping with Life in Rebel Captivity and the Challenge of Reintegrating Formerly Abducted Boys in Northern Uganda Journal of Refugee Studies 2007, 20(4):641-661 Corbin JN: Returning home: resettlement of formerly abducted children in Northern Uganda Disasters 2008, 32(2):316-335 Page 13 of 14 (page number... and community acceptance and support are vital to psychosocial well-being of former LRA abductees [15] It shows the value of reintegrating former abductees with their families and developing programs to help them move ahead economically and socially At the same time, the study did not find a significant association between social relationships and symptoms of PTSD, suggesting that the reintegration... stressing the confidential and anonymous nature of the interviews Adapting the language and western concepts used in measuring psychological trauma to nonWestern populations may result in trans-cultural errors However, we consulted with local experts and other researchers during the development of our research instrument, and we had successfully implemented a similar study in northern Uganda in 2005 The. .. in Uganda, and analyzed the data PNP, PV, and ES interpreted the data and wrote the report All authors read and approved the final manuscript Acknowledgements Conclusion We found high prevalence rates of symptoms of PTSD and depression among former LRA abductees in northern Uganda The symptoms were associated with directly experiencing violence, being forced to commit violent acts, and/ or witnessing... statistically significant above: 1) length of abduction, 2) going through a reception center, 3) being married or in partnership relationship Discussion those held in captivity for less than one day were released by the LRA The LRA may have abducted as many people as they could during a raid to help them carry stolen goods and also enable them to select the fittest individuals for their army One-third of the. .. dichotomized the scores for the criteria for symptoms of PTSD and depression using two cut-off points: symptoms of PTSD (cutoff score of 44) and depression (cutoff score of 42) The two cut-off scores are chosen because they yielded the most conservative estimates and permitted us to conduct logistic regression It is possible that more respondents had symptoms of PTSD and depression than reported Finally, causal... acts of violence Symptoms of depression were more likely among individuals who had been directly exposed to violence and forced to commit acts of violence Secondary exposure (e.g direct exposure of family members) was associated with neither symptoms of PTSD nor symptoms of depression This suggests that beyond the "dose-effect" model linking increased exposure to violence with an increase in psychological... Depression Symptom Checklist (JHD) The use of standard scales to measure the symptoms of psychological disorders such as PTSD and depression has been widely debated Critics generally stress the lack of validity of those measurements because they are applied in different cultural environment and in conflict situations [19-21] Those measures were nevertheless included in our analysis because they are validated . disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychi- atry 2008, 8:38. 12. Vinck P: In the Eyes of Victims: Peace and Justice in Northern Uganda., in International. the Challenge of Reintegrating Formerly Abducted Boys in Northern Uganda. Journal of Refugee Studies 2007, 20(4):641-661. 15. Corbin JN: Returning home: resettlement of formerly abducted children in Northern. found family and community play an important role for the psy- cho-social well being of former abductees [15]. Thus addressing psychological trauma and helping former abductees reunite with their family